Still waiting: poor access to sexual health services in the UK
http://www.100md.com
《性传输感染医学期刊》
1 Department of Infectious Disease Epidemiology, Imperial College London, London W2 1PG, UK
2 President, British Association of Sexual Health and HIV (BASHH), Department of Genitourinary Medicine, Mortimor Market Centre, Camden PCT, WC1E 6AU, UK
"Love Hurts," suggested the BBC’s Panorama programme in October last year. The investigation focused on the rising rates of sexually transmitted infections in the UK and the crisis in access to genitourinary medicine (GUM) clinics.1 It took as it’s starting point the centrality of sexual health in the 2004 Public Health White Paper for England, Choosing Health.2 The Government is committed to a major sexual health education programme starting in 2006 and major improvements in sexual health services. To monitor progress local health service organisations have been set targets, including one relating to patient access: by 2008, all patients should be offered an appointment within 48 hours of contacting a GUM clinic.
Poor access to sexual health services has been highlighted as one factor contributing to continued increases in sexually transmitted infections,3 and a number of surveys have found access to clinics have worsened over the past decade.4,5 Many clinics changed from walk-in to appointment-based services, and the expansion of demand has far outstripped the capacity. BASHH recently noted that, "over the past 10 years, services have more than doubled capacity through extensive service modernization despite less than 10% increase in resource".6 Some clinics have re-introduced more walk in services and triage systems to prioritise patients most likely to have an STI; they have also introduced asymptomatic screening clinics.
The BBC programme included results of a national "mystery shopper" survey specially commissioned for the programme. Researchers telephoned all GUM clinics in the UK posing as patients with three scenarios: wanting a routine check, having symptoms of an STI or being a contact of someone with gonorrhoea. A summary of the results is available on the programme website.1 These results will come as no surprise to front-line service providers in the UK, but paint an even grimmer picture than the routine audit of waiting times carried out by the Health Protection Agency and BASHH.7
According to the BBC, only 7% of clinics in the UK could offer a routine appointment within 48 hours, with average waiting of between 7 days in the South of England and 28 days in Northern Ireland. Results were better for callers reporting symptoms of an STI (73% of clinics could see them within 48 hours) and those reporting contact with a case of gonorrhoea (70%).
The HPA/BASHH audit (for England) measures waiting times differently through asking patients registering at a clinic how long they have waited since first contacting the clinic. Unlike the BBC survey, this audit will miss out on patients who give up completely or go elsewhere (to a GP or an Accident and Emergency Department for example). Latest results (from the August 2005 survey) were published recently and show that 48% of patients were seen within two working days.7 This is a small improvement on the 45% from May 2005, but this may be due to seasonal fluctuation or minor changes in the way the clinics carry out the audit.
The results of both these surveys show the huge gap between where we are now and the 2008 target. Further evidence is provided in a paper in this issue, from Clarke and colleagues in Leeds.8 They estimated demand for appointments over a one week period, and found that to be able to offer an appointment to all patients within 48 hours, they would need 626 appointment slots each week, three and a half times their capacity of 181 slots. With this level of mismatch between demand and supply, efficiency through modernisation seems unlikely to be sufficient to close the gap. A massive expansion of capacity, and therefore resource, is needed.
Some clinics have responded to the 48 hour target by introducing restrictive booking systems in which patients can only book appointments up to 2 days in advance. Such systems became widespread in primary care after a similar target was introduced there, and have been widely condemned by patients, a fact revealed to a seemingly baffled Mr Blair during the 2005 election campaign. Almost one in five have introduced restrictive booking according to Panorama. This is just one of a number of unintended consequences of this type of target. Although perhaps understandable as a way of coping with huge demand, we do not support restrictive booking as it creates major difficulties for patients trying to access services.
There is clealry a continued crisis in GUM services in the UK. The government has earmarked money for investment in services, but it is becoming clear that a considerable proportion of this will not reach sexual health as many primary care trusts struggle with deficits and other priorities. But to neglect this area will not just mean patients inconvenienced by long waits. These are infectious conditions, and increased waiting will lead to increased transmission of STI and potentially of HIV infection. Improving access to STI diagnosis and treatment services must be a public health priority at all levels. Funders should be reminded that failure to deliver on this infection control measure will cost the public purse dearly in the long run.
REFERENCES
BBC Panorama. Love Hurts. Details, transcript and results of the survey are available at http://news.bbc.co.uk/1/hi/programmes/panorama/4334310.stm, accessed 4 January 2006.
Department of Health. Choosing health: making healthier choices easier. London: Department of Health, 2004.
White PJ, Ward H, Cassell JA, Mercer CH, Garnett GP. Vicious and virtuous circles in the dynamics of infectious disease and the provision of health care: gonorrhoea in Britain as a model. J Infect Dis 2005;192:824–836.
Djuretic T, Catchpole M, Bingham JS, Robinson A, Hughes G, Kinghorn G. Genitourinary medicine services in the United Kingdom are failing to meet current demand. Int J STD AIDS 2001;12:571–2.
Foley E, Patel R, Green N, Rowen D. Access to genitourinary medicine clinics in the United Kingdom. Sex Transm Infect 2001;77:12–14.
BASHH Modernisation subgroup. Capacity building to reach 48 hour access; making the case to PCTs. Available at www.bashh.org/committees/cgc/funding/capacity_increase_48h_access_190905.doc, accessed 4 January 2006.
HPA/ BASHH. Waiting times for Genitourinary Medicine clinics – results from August 2005 audit. Available at www.hpa.org.uk/infections/topics_az/hiv_and_sti/epidemiology/results.htm, accessed 4 January 2006.
Clarke J, Christodoulides H, Taylor Y. Supply and demand: estimating the real need for care while meeting the 48-hour waiting time target in a genitourinary medicine by a closed appointment system. Sex Transm Infect 2006;82:45.(H Ward1 and A J Robinson2)
2 President, British Association of Sexual Health and HIV (BASHH), Department of Genitourinary Medicine, Mortimor Market Centre, Camden PCT, WC1E 6AU, UK
"Love Hurts," suggested the BBC’s Panorama programme in October last year. The investigation focused on the rising rates of sexually transmitted infections in the UK and the crisis in access to genitourinary medicine (GUM) clinics.1 It took as it’s starting point the centrality of sexual health in the 2004 Public Health White Paper for England, Choosing Health.2 The Government is committed to a major sexual health education programme starting in 2006 and major improvements in sexual health services. To monitor progress local health service organisations have been set targets, including one relating to patient access: by 2008, all patients should be offered an appointment within 48 hours of contacting a GUM clinic.
Poor access to sexual health services has been highlighted as one factor contributing to continued increases in sexually transmitted infections,3 and a number of surveys have found access to clinics have worsened over the past decade.4,5 Many clinics changed from walk-in to appointment-based services, and the expansion of demand has far outstripped the capacity. BASHH recently noted that, "over the past 10 years, services have more than doubled capacity through extensive service modernization despite less than 10% increase in resource".6 Some clinics have re-introduced more walk in services and triage systems to prioritise patients most likely to have an STI; they have also introduced asymptomatic screening clinics.
The BBC programme included results of a national "mystery shopper" survey specially commissioned for the programme. Researchers telephoned all GUM clinics in the UK posing as patients with three scenarios: wanting a routine check, having symptoms of an STI or being a contact of someone with gonorrhoea. A summary of the results is available on the programme website.1 These results will come as no surprise to front-line service providers in the UK, but paint an even grimmer picture than the routine audit of waiting times carried out by the Health Protection Agency and BASHH.7
According to the BBC, only 7% of clinics in the UK could offer a routine appointment within 48 hours, with average waiting of between 7 days in the South of England and 28 days in Northern Ireland. Results were better for callers reporting symptoms of an STI (73% of clinics could see them within 48 hours) and those reporting contact with a case of gonorrhoea (70%).
The HPA/BASHH audit (for England) measures waiting times differently through asking patients registering at a clinic how long they have waited since first contacting the clinic. Unlike the BBC survey, this audit will miss out on patients who give up completely or go elsewhere (to a GP or an Accident and Emergency Department for example). Latest results (from the August 2005 survey) were published recently and show that 48% of patients were seen within two working days.7 This is a small improvement on the 45% from May 2005, but this may be due to seasonal fluctuation or minor changes in the way the clinics carry out the audit.
The results of both these surveys show the huge gap between where we are now and the 2008 target. Further evidence is provided in a paper in this issue, from Clarke and colleagues in Leeds.8 They estimated demand for appointments over a one week period, and found that to be able to offer an appointment to all patients within 48 hours, they would need 626 appointment slots each week, three and a half times their capacity of 181 slots. With this level of mismatch between demand and supply, efficiency through modernisation seems unlikely to be sufficient to close the gap. A massive expansion of capacity, and therefore resource, is needed.
Some clinics have responded to the 48 hour target by introducing restrictive booking systems in which patients can only book appointments up to 2 days in advance. Such systems became widespread in primary care after a similar target was introduced there, and have been widely condemned by patients, a fact revealed to a seemingly baffled Mr Blair during the 2005 election campaign. Almost one in five have introduced restrictive booking according to Panorama. This is just one of a number of unintended consequences of this type of target. Although perhaps understandable as a way of coping with huge demand, we do not support restrictive booking as it creates major difficulties for patients trying to access services.
There is clealry a continued crisis in GUM services in the UK. The government has earmarked money for investment in services, but it is becoming clear that a considerable proportion of this will not reach sexual health as many primary care trusts struggle with deficits and other priorities. But to neglect this area will not just mean patients inconvenienced by long waits. These are infectious conditions, and increased waiting will lead to increased transmission of STI and potentially of HIV infection. Improving access to STI diagnosis and treatment services must be a public health priority at all levels. Funders should be reminded that failure to deliver on this infection control measure will cost the public purse dearly in the long run.
REFERENCES
BBC Panorama. Love Hurts. Details, transcript and results of the survey are available at http://news.bbc.co.uk/1/hi/programmes/panorama/4334310.stm, accessed 4 January 2006.
Department of Health. Choosing health: making healthier choices easier. London: Department of Health, 2004.
White PJ, Ward H, Cassell JA, Mercer CH, Garnett GP. Vicious and virtuous circles in the dynamics of infectious disease and the provision of health care: gonorrhoea in Britain as a model. J Infect Dis 2005;192:824–836.
Djuretic T, Catchpole M, Bingham JS, Robinson A, Hughes G, Kinghorn G. Genitourinary medicine services in the United Kingdom are failing to meet current demand. Int J STD AIDS 2001;12:571–2.
Foley E, Patel R, Green N, Rowen D. Access to genitourinary medicine clinics in the United Kingdom. Sex Transm Infect 2001;77:12–14.
BASHH Modernisation subgroup. Capacity building to reach 48 hour access; making the case to PCTs. Available at www.bashh.org/committees/cgc/funding/capacity_increase_48h_access_190905.doc, accessed 4 January 2006.
HPA/ BASHH. Waiting times for Genitourinary Medicine clinics – results from August 2005 audit. Available at www.hpa.org.uk/infections/topics_az/hiv_and_sti/epidemiology/results.htm, accessed 4 January 2006.
Clarke J, Christodoulides H, Taylor Y. Supply and demand: estimating the real need for care while meeting the 48-hour waiting time target in a genitourinary medicine by a closed appointment system. Sex Transm Infect 2006;82:45.(H Ward1 and A J Robinson2)